E0733 — Transcutaneous electrical nerve stimulator for electrical stimulation of the trigeminal nerve
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- "Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the service requested; refer to the protocol titled Medical Records Documentation Used for Reviews."
- Documentation of medically refractory epileptic seizures (drug-resistant epilepsy), e.g., evidence that the patient has failed two or more trials of single or combination antiepileptic drug therapy or had intolerable side effects (names/duration/response to AEDs).
- Documentation that the individual is not a candidate for epilepsy surgery, has failed epilepsy surgery, or explicitly refuses epilepsy surgery after a Shared Decision Making discussion (record of the shared decision making discussion and rationale).
- Documentation confirming no history of left or bilateral cervical vagotomy (to demonstrate absence of this FDA-identified contraindication).
Key Coverage Criteria
- Implantable vagus nerve stimulators are proven and medically necessary for treating epilepsy in individuals with all of the following:
- Medically refractory epileptic seizures with failure of two or more trials of single or combination antiepileptic drug therapy or intolerable side effects of antiepileptic drug therapy; and
- The individual is not a candidate for epilepsy surgery, has failed epilepsy surgery, or refuses epilepsy surgery after Shared Decision Making discussion; and
- No history of left or bilateral cervical vagotomy. The U.S. Food and Drug Administration (FDA) identifies a history of left or bilateral cervical vagotomy as a contraindication to vagus nerve stimulation.
- Transection of corpus callosum (callosotomy) — CPT 61541, covered if selection criteria are met
- Cerebral hemispherectomy when all selection criteria are met, including members with unilateral multi-focal epilepsy associated with infantile hemiplegia (especially in hemimegalencephaly and Sturge-Weber disease).
9 Active Policies
CIGNA-0160-FUTURE — Electrical Stimulation Therapy and Devices in a Home Setting - (0160)
CIGNA-0160 — Electrical Stimulation Therapy and Devices in a Home Setting - (0160)
AETNA-CPB-0078 — Learning Disabilities, Dyslexia, and Vision
AETNA-CPB-0374 — Trigeminal Neuralgia: Treatments
AETNA-CPB-0394 — Epilepsy Surgery
Related Codes
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